Healthcare Provider Details

I. General information

NPI: 1720508062
Provider Name (Legal Business Name): FUAD BASHJAWISH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2017
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 CONVERY BLVD
PERTH AMBOY NJ
08861-1937
US

IV. Provider business mailing address

25212 ECHO LAKE DR
WHARTON NJ
07885-1265
US

V. Phone/Fax

Practice location:
  • Phone: 862-686-6055
  • Fax:
Mailing address:
  • Phone: 862-686-6055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MB11163800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: